Thursday, January 31, 2019

A memorable case discussion attended by the second author featured a consultant recommending multi-systemic treatment (MST) for an adolescent who had been acting out aggressively ever since his father’s death. The case manager was concerned about his behaviour and had just overseen an unsuccessful course of MST with this client. Despite the fact that MST hadn’t worked, the consultant recommended that it be repeated, not because it was the correct intervention for that particular individual (for whom grief counselling might also have been appropriate), but because of the strength and quality of the MST research. The situation calls to mind words from a UK practitioner during a conference in 2012: Are we personalizing our manuals or manualizing our persons?

It often seems that our field is governed by large-scale studies and quantitative evidence indicating that a particular treatment, intervention, or process either works or doesn’t work. Understandably, we look at the broader outcomes of re-offense and risk reduction to drive future processes. We (the authors) are not saying that this is wrong, but rather that practitioners should remember the individual in the process, as well as the greater cohort. Sexual abuse (and treatment for sexual abuse) is as much about personal narratives and context as it is about processes and outcomes. Sadly, our most sacred studies don’t always take into account the experiences of those who have lived through the interventions.

The prevention, treatment, and management of people who have committed, or may commit, sexual offences include features that range from the individual through to the social and cultural. One implication is that we must use multiple research methodologies to answer a range of questions that include the “service user”, the “service provider” and the facilitating institution; their “voices”. A single research methodology, epistemology, ontology, or form of data analysis will not work in all circumstances; especially given that research and practice linked to sexual abuse cross many social (politics, law, policy, sociology, criminology, psychology) and physical (chemistry, biology, psychology) disciplines, and everything in between (public health). We need quantitative studies to look at large cross-population samples and answer broad-based questions. However, is a quantitative approach the best one for small-scale, small-cohort, individualised, practice-based, policy-based or process-driven questions? No, it isn’t. We often need to consider case studies or qualitative research methods to answer these more personalised, individualized, and small cohort questions. The research question, who is asking it and why they are asking it are central drivers as different disciplines and different groups have different agendas; which is fine, as long as its transparent and clear!

We need to use the research (and treatment) method that enables us to answer the question that we are asking. We can’t fit a particular research question into a certain methodology for artificial reasons because, in reality, it will fail and jeopardise the outcome. Certain research questions linked to prevention, treatment, management, and community integration need to be qualitative so that we can capture the appropriate narrative and understand whether the process or intervention is working at a ground level. We need a qualitative, or case-focused, approach to hear and understand the “service user” experience, or the expert voice, within the cohort sample and larger outcome. This is essential, because we need to connect research and treatment in a coherent way that does not create paradigm extremes (quantitative being the choice of “research” and qualitative being the choice of “treatment”). This happy medium incorporates multi-stage, multi-methodology, and multi-disciplinary studies in order to focus on the larger research questions as well as capturing the personal narrative. A multi-methodology approach enables us to explore treatment, research, and policy questions and facilitates a more holistic response.

Working in a politically, socially, and personally sensitive area demands that we think ethically about the research that we do and the way that we do it. Often times we need to do the complex, expensive research study that allows us to understand the reality of the situation. Unfortunately, this type of research does not happen as much, or in as much of a nuanced way, as it should.

The scholarly literature, for instance,
about non-offending minor attracted persons (MAPs) is in a nascent stage. Though
they remain an under-studied and somewhat misunderstood population, we are
learning more about individuals who have sexual interests in children (Cantor
& McPhail, 2016). Studies have revealed that most MAPs become aware of
their unusual sexual interests in early adolescence (B4UAct, 2011b; Buckman,
Ruzicka, & Shields, 2016), and that among MAPs, about 42% report a primary
attraction to pre-pubescent youngsters (Mitchell & Galupo, 2016; Piché,
Mathesius, Lussier, & Schweighofer, 2016).

Due to stigma, fear, and shame, and many
other factors, many MAPs have not sought help from professionals, and others
have been discouraged by the services they received (Jahnke, 2018). Some MAPs who did seek services but did not receive them reported that
failure to obtain adequate help resulted in negative ramifications. These
include an exacerbation of mental health symptoms such as depression,
suicidality, withdrawal and isolation, lost productivity, fear and anxiety,
hopelessness, and substance abuse (B4UAct, 2011a). Furthermore, a small group
(3-4%) said that after being unable to obtain counseling, their attraction to
youngsters continued or escalated and that they were later convicted of a
sexual crime (B4UAct, 2011a). MAPs in non-forensic samples tend to have higher
education and socio-economic status than those convicted of sex crimes, and may
have greater willingness and opportunity to engage in formal and informal
help-seeking through various professional or online resources.

The project complemented information gained
from the “Help Wanted” project developed by Dr. Elizabeth Letourneau [described
in Buckman, Ruzicka & Shields (2016)] by collecting data from a larger
sample with a greater age range. The quantitative survey for more robust data
analyses including group comparisons and associations between variables.

Good
data and collaborations

The researchers built relationships to
partner with consumer groups that provide online support, resources, education,
and information for MAPs who are concerned about their sexual interest in
children. With the help of organizations like Stop It Now! and VirPed, the
project was able to collect a non-random, purposive sample of MAPs (n = 293; 154 completed all questions).
The on-line survey included quantitative questions to gather information about
their histories, help-seeking experiences and behaviors, as well as 10
open-ended prompts designed to capture their lived experiences of seeking counseling
for minor-attraction.

Overcoming
challenges

Confidentiality and anonymity concerns were
addressed by building in protections in the survey platform. Many MAPs have
worked to separate the constructs of minor-attraction or pedophilia from “sex
offender.” The conflation of these terms perpetuates the stigma and shame felt
by MAPs. For this reason, some MAPs did not want to be part of a study focused
on the prevention of sexual abuse, arguing that many MAPs are not at risk for
abuse.

This project promotes the idea that we can
make communities safer when we provide compassionate, relevant, ethical, and
effective psychotherapy services accessible and available for non-offending
MAPs who wish to maintain an emotionally healthy and non-victimizing lifestyle.

Mitchell, R. C., & Galupo, M. P.
(2016). The role of forensic factors and potential harm to the child in the
decision not to act among men sexually attracted to children. Journal of
Interpersonal Violence, 0886260515624211.

Thursday, January 17, 2019

I recently had the opportunity to provide training on the Good Lives Model and Feedback-Informed Treatment in a secure treatment center for adolescents. The program has been able to accomplish what others only dream of with kids deemed by the courts to need this intensive level of supervision and structure. After the training, I had the privilege of meeting with a number of treatment graduates as well as their student advisory board, an independent collection of students currently in treatment. I also toured the facility, observed people and situations, often beyond their full awareness, etc. Just imagine:

·In a program that serves well over 100 adolescents, they have not had to engage in physical management in over 560 days.

·As a part of eliminating physical management, they also reduced the number of staff injuries significantly.

·They present at national conferences on the methods they used to accomplish this remarkable feat. The short version is that it involves strong leadership, a philosophy of trusting kids to do the right thing under the right circumstances, and intensive in-house training on how to have a conversation with a distressed teenager and how to prevent appearing threatening.

·The program was an early adopter of trauma-informed care and has used trauma-focused cognitive behavioral therapy for the better part of a decade.

·They incorporate client feedback in a number of areas through the use of anonymous surveys. The process itself is further anonymized through the way staff members handle each survey.

·The student advisory board takes an active role in the hiring of staff and has actually contributed substantively, including accurately identifying candidates who were unfit to hire.

·Taken in sum, the program has worked like very few others to develop a “culture of feedback” in which its students are free to speak with staff at all levels about their doubts and concerns. They are able to do so without fear of retribution and with confidence that they will be taken seriously. In a large institution, this is itself a major accomplishment.

·The program tracks outcomes and finds that only a small number of its clients return to a similar or higher level of care. They break this data down further to identify which clinicians are more and less successful in this regard so that all can improve the services they deliver.

Although there are good and not-so-good youth-serving programs all around North America, what makes one of the biggest differences? This program uses the polygraph. Those familiar with my work know that I have long been sceptical of the polygraph with adolescents. As just one example, consider this post by myself, Kieran McCartan, and Alissa Ackerman from last year, in which we discussed how the success of an intervention can rise and fall on its implementation.

To a sceptic such as myself, this implementation comes as a refreshing surprise. From internal data collected, it is clear that the majority of clients are not only comfortable with the polygraph as it is implemented but endorse its use wholeheartedly. Comments from students who had nothing to gain or lose by being honest in interviews focused on how the process of using the polygraph helped them to be honest with themselves about their treatment needs. Inconclusive results were as likely to activate discussions in treatment as to the possible role of adversity and trauma in the backgrounds of the students as anything else. Policies are in place that firmly establishes its use as a treatment tool. In fact, to an outside observer like myself, it appeared that the program had worked to wrest polygraph processes away from professionals outside the program in order to implement its use in the context of the client-centered values described above.

Of course, some aspects of this program’s polygraph use are clearly at variance with other implementations and deserve comment. I have personally worked with some polygraph examiners who should probably never work with adolescents. That is a fair enough statement, as I have also spoken with examiners who don’t want to work with this population. Likewise, this program has no expectation that the polygraph will do anything except help teens to demonstrate to themselves or others that they are giving treatment, honesty, and meaningful personal change their best shot. Importantly, in the context in which these young people find themselves (entangled in the legal system and often at odds with their families), they are grateful for anything that helps them to get back on track quickly.

In addition to their consumer satisfaction and feedback measures, the program further uses these approaches to ensure that the polygraph is helping and not hurting any of the kids or their futures. Questions related to how comforting the examiner was to the child are at the forefront of questionnaires and clinical discussions; indeed, the students give specific feedback on the examiners themselves. Just as importantly, the polygraph is billed as something that confirms students’ statements rather than catching them lying. Ultimately, there is no over-selling or misrepresentation of the polygraph; the students are aware that it is far from perfect, and this is evidenced in their feedback.

Ultimately, any intervention can do harm when misapplied. This is why we have practice guidelines and codes of ethics. I have personally witnessed polygraph examinations that were anything but helpful. Unfortunately, as with other agency settings, it is a very difficult process to obtain approval for research from the court system involved. For the time, it is limited to its own practice-based evidence. At the present time, the program is continuing to work to improve. For example, while a very considerable majority felt that the polygraph process had helped them to forge better relationships with others, a majority also felt that they could have been better prepared.

In all, I left the experience feeling that the real question is not whether the polygraph should be used or not, but rather how programs can best focus on all of the myriad elements that make up a solid, youth-guided intervention. Although I have no plans to change my own practice, this experience points to the obvious need for professionals to keep an open mind and not simply assume that any other professional is either wrong or in need of instruction.

The challenge for practitioners in the field ultimately has to do with balancing the promise of better futures with minimal risk of harm. Like many other aspects of treatment (e.g., disclosing past abuse without the polygraph, focusing on victim empathy), it can take years of teamwork to accomplish this.

Tuesday, January 8, 2019

It’s a little late for this to be a 2018 year in review post, but if I had to pick a single study from the last year with maximum implications for professionals working with people who abuse (whether sexually or otherwise), it would be one by Brandy Blasko and Faye Taxman. They found that “when the community supervision process was perceived [by the client] as procedurally fair, individuals under community supervision demonstrated positive criminal justice outcomes, that is, less self-reported criminal behavior, fewer official arrests, and fewer technical parole violations” (p. 414). Their measure of fairness included the client’s perception of being listened to by their probation officer.

Why is this study so important? For starters, it adds to what over 1,100 studies have found outside of forensic treatment circles: that the therapeutic alliance (also known as the working alliance) is fundamental to making treatment effective. And yet, too few in our field can even define it. Of course, developing any kind of professional relationship with people whose actions have been reprehensible can be a challenge, especially for those starting out in the field.Bill Marshall and his colleagues found that the most effective treatment providers are warm, empathic, rewarding, and directive, but translating these qualities into one’s own practice can be a challenge.

Questioning the nature of professional relationships is not merely an academic point. Sexual and other forms of violence can cut deeply into the hearts and souls of professionals, as anyone who has followed the recent media attention to R. Kelly can attest. Virtually anyone who works in the areas of abuse and trauma has experienced those cases that leave a lasting mark on our souls, often with apparently indelible imagery. As some have recently noted, when the person who perpetrates violence has been a hero or practically wrote the soundtrack to one’s adolescence, the resulting anguish can be hard to escape and even contribute to burnout.

Recent discussions within and outside of ATSA circles have focused both on the impact of doing this work and the extent to which we should “like” our clients. To outsiders, one of the surprises of working in our field is how likable some of our clients can actually be. In some cases, this can become disconcerting, leading to questions as to where the boundaries are in developing the best working relationship. Complicating matters are the moral judgments professionals can have about their client’s actions, as well as concerns that their clients may be engaged in manipulation processes that resemble the approach behaviors used with those they’ve harmed. With all of these factors in the mix, how could we not wonder about what kind of relationship is most effective? Even beyond likability, many of us remember that the teachers, coaches, and colleagues we learned the most from were not necessarily those that we liked the best, but we respected them.

“What is the right relationship” may not, however, be the best question. Just as there are “treatments of choice”, there can also be “relationships of choice” … And these can vary based on who the therapist is. Implied within the Blasko and Taxman study is that it’s not a question about what kind of relationship you have as much as do you have agreement and buy-in as to the nature of your relationship. Very often, this centers on to what extent you have built up agreement on the goals you are working towards and the approaches used in treatment. This agreement on the nature of the relationship as well as the goals and tasks of treatment are the three areas originally defined byEdward Bordin in 1979. Although mentioned frequently in trainings and social media (including this article by Scott Miller and me, and a blog post with our colleagues), it often appears to be an idea whose time is yet to come in the forensic arena.

One way to think about building the “right” relationship with clients might be to think about it one client at a time. You can ask yourself:

1.What are this client’s goals and how can I best align them with the goals set out in his (or her) treatment plan and/or assessment reports?

2.What kind of approach works best with this particular client and how can we develop agreement on the best way forward?

3.Who am I to this client and how does s/he view my role within it? Do we have agreement on who I am to this person?

4.Finally, how can I provide services in a way that are aligned with this person’s unique culture and strongly held values?

Seen through this lens, the question of the right relationship (and the boundaries within which it exists) may be easier to negotiate.

Of course, what is missing from this mix can be as important as what is there. In this way of working, professionals must strive to keep whatever moral judgements they have about clients’ actions separate from the assessment or treatment process itself. Likewise, it can be easy to overlook the importance of establishing agreement in these areas to begin with; all too often, professionals view the working alliance as something to establish at the start of treatment rather than an essential component throughout the experience. Finally, it can be tempting to think that we already have a good enough working alliance, and that we don’t need to ensure this on an ongoing basis. Unfortunately, Beech and Fordham found otherwise in our field. Finally, it assumes that professionals are willing to take into account their clients’ experiences, are able to think flexibly about their clients, and be willing to switch up their styles as needed.

In the end, however, I’ve always found that the additional attention to these areas pays dividends in terms of time saved trying to sort out why treatment isn’t moving faster.

Kieran McCartan, PhD

Chief Blogger

David Prescott, LICSW

Associate blogger

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The Association for the Treatment of Sexual Abusers (http://atsa.com/) is an international, multi-disciplinary organization dedicated to preventing sexual abuse. Through research, education, and shared learning ATSA promotes evidence based practice, public policy and community strategies that lead to the effective assessment, treatment and management of individuals who have sexually abused or are risk to abuse.

The views expressed on this blog are of the bloggers and are not necessarily those of the Association for the Treatment of Sexual Abusers, Sexual Abuse: A Journal of Research & Treatment, or Sage Journals.

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